Laserfiche WebLink
Operator(If Other than Pennittee): <br /> Permittee Representative: Scott Pottorff Wor Dana Cline <br /> Certified Mail #��G v� ;�C� 6,; 7. Z�Y5- <br /> In accordance with Rule 4.17.1(2)the Operator shall include the names,addresses and phone numbers of all <br /> owners of record to the affected land. Please attach additional sheets for this information if required. <br /> Name Address Phone Number <br /> Dept of Energy 2597 Legacy Way Grand Jct, CO 81503 970-248-6000 <br /> In accordance with Rule 4.17.1(4), if requesting a partial acreage release the Operator or their agent MUST sign that <br /> they have complied with the following statement: "All applicable portions of the Reclamation Plan requirements <br /> have been satisfied in accordance with these Rules and all applicable requirements under the Act." <br /> ignature of PT6tteel, Operator or their authorized agent Da <br /> Important: In accordance with Rules 4.14.20) and 4.17.1(3) This release reguest must be submitted to the <br /> Division via certified mail and separate_from any other correspondence to the Division. <br /> SLnetalsReleaseRequemForm 20Sep2017 <br /> Page 2 of 2 <br />